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Summary universal c Summary universal c Presentation Transcript

  • UNIVERSAL C/S THROMBOPROPHYLAXIS DECEMBER2011 RIVERSIDE
  • Recommendations for thromboprophylaxis following C-SECTION
    • The need for thromboprophylaxis for preventing venous thromboembolism in asymptomatic, pregnant women with identifiable risk factors in both the antepartum and postpartum period has not been defined in clinical trials .
    • Currently, thromboprophylaxis is prescribed based on EXPERT OPINION guideline recommendations and assessment of risks and benefits of anticoagulant therapy. The decision to use thromboprophylaxis should be made on the basis of each patient’s risk assessment, with continuation of low-molecular- weight heparin and the use of compression stockings for up to 6 weeks in selected high-risk patients in whom important risk factors persist after delivery
    • Broad practical guidelines (ACCP/ NICE / RCOG /ACOG ) for LMWH THROMBOPROPHYLAXIS AFTER CESAREAN SECTION ARE IN AGREEMENT WITH GENERAL CONSENSUS for clinical practice. However, it is recognized that, in individual women, alternative approaches may be reasonable, particularly following discussion with the woman concerned
  • ACOG / RCOG / ACCP / NICE Recommendations ; Thromboprophylaxis Following Cesarean Section
    • 1) For women considered at HIGH risk of VTE after cesarean section because of the presence
    • At least one HIGH RISK FACTOR in addition to a C-section ( SCORE OF 3 OR MORE) FOR @ LEAST 7 DAYS
    • BMI > 40
    • LOW RISK THROMBOPHILIA
    • MEDICAL CO-MORBIDITIES
    • > 3 DAYS IMMOBILAZATION PRIOR TO SURGERY
    • SURGERY DURING PREGNANCY OR POSTPARTUM
    • EMERGENCY C-SECTION OR HYSTERECTOMY
    • 2) Pharmacologic Thromboprophylaxis (PROPHYLACTIC LMWH AND MECHANICAL PROPHYLAXIS ) FOR @ LEAST 7 DAYS
    • For women with TWO OR MORE additional risk factors for thromboembolism who are undergoing cesarean section are considered to be at very high risk of VTE, we suggest that pharmacologic prophylaxis be combined WITH intermittent pneumatic compression (Grade 2C).
    • For selected high-risk patients in whom important risk factors persist following delivery, ( HIGH RISK THROMBOPHILIA OR REQUIREMENT FOR ANTENATAL THOMBOPROPHYLAXIS) we suggest extended prophylaxis (up to 4 to 6 weeks after delivery ) following discharge from hospital (Grade 2C)
  • 7 DAY SCD MULTIPLE GESTATION Emergency cs Hysterectomy MULTIPLE GESTATION Anticoagultion LMWH
  • y y y y lmwh R I S K F A C T O R S Y SCORE OF 3 OR HIGHER CONSIDER @ LEAST 7 DAYS OF LMWH LOVENOX +SCD 1 Weight < 50 kg = 20 mg Lovenox/ Q 24 Weight 50–90 kg = 40 mg Lovenox/ Q 24 Weight 91–130 kg = 60 mg Lovenox/ Q 24 Weight 131–170 kg = 80 mg Lovenox/ Q 24 Weight > 170 kg = 0.6 mg/kg/day h eparin prophylactic dose 5000 -8,000 no sooner than 1 hour prior to spinal or epidural / SCD PRIOR TO SPINAL lovenox administration 8-12 hours after c/s and no sooner than 2 hours after removal of epidural catheter POSTPARTUM TREATMENT SHOULD BE >/= TO ANTEPARTUM TREATMENT
  • IF PATIENT GAINS 20% OR MORE FROM 1 ST TRIMESTER WEIGHT CHECK LEVELS 4 HRS AFTER 3 RD DOSE
    • Tailor treatment to individual WEIGHT IF NECESSARY
    • Prophylaxis LMWH 40mg SQ/24 hrs
        • Lovenox AntiXa 0.2-0.4
    • Intermediate LMWH 40mg SQ/12 hrs
    • Lovenox AntiXa 0.4-0.6
    • Adjusted dose LMWH 1mg/Kg/12hrs
    • Lovenox AntiXa 0.5-1.0
  • VTE Risk factors Defined
    • BMI >/=40 (based on 1 st trimester weight or prepregnancy weight)
    • Gross varicose veins = symptomatic, above the knee or associated with phlebitis/edema/skin changes
    • MEDICAL COMORBIDITIES :heart failure or severe lung disease, SLE, cancer, inflammatory conditions (inflammatory bowel disease or inflammatory polyarthropathy), nephrotic syndrome (proteinuria >3 g/day), sickle cell disease, intravenous drug user
    • Immobility or clinically significant reduced mobility = ≥ 3 days
    • long-distance travel = > 4 hours
    • Systemic infection (requiring antibiotics or admission to hospital) (e.g., pneumonia, pyelonephritis, postpartum wound infection)
    • surgery during pregnancy OR after delivery e.g. appendectomy OR P ostpartum tubal ligation
    • OHSS = ovarian hyperstimulation syndrome,
    • PPH = postpartum hemorrhage, (>1 liter ) or requiring transfusion
  • Recommendations for thromboprophylaxis following delivery
    • High risk At least 6 weeks postnatal ANTICOAGULATION LMWH
    • Intermediate risk At least 7 days postnatal prophylatic LMWH
    • Note: if persisting or > 3 risk factors, consider extending thromboprophylaxis with LMWH FOR DURATION OF RISK FACTOR OR 6 WEEKS
    • SUGGESTED THROMBOPROPHYLAXIS DOSING
    • Weight < 50 kg = 20 mg enoxaparin/ Q 24
    • Weight 50–90 kg = 40 mg enoxaparin/ Q 24
    • Weight 91–130 kg = 60 mg enoxaparin/ Q 24
    • Weight 131–170 kg = 80 mg enoxaparin/ Q 24
    • Weight > 170 kg = 0.6 mg/kg/day enoxaparin/Q 24
  • ARSA GUIDELINES EPIDURAL & LMWH
    • 12 hours after last prophylactic lmwh dose epidural can be placed
    • 24 hours after last full anticoag dose epidural can be placed
    • PP start prophylaxis 2 hrs after removal of catheter
    • PP full anticoag (Lovenox/Coumadin) 24 hrs after removal of catheter
    • Reg Anesth Pain Med 2003;28:172
    • Reg Anesth Pain Med 2010;35:64
  • HIT
    • Acute systemic “allergic reaction” fever, chills, hypertension, tachycardia, chest pain, dyspnea
    • Check platelet count @ initiation of therapy and weekly for 3 weeks
    • Day 5 – 7 platelets begin decline < 150K
    • Day 10 – 14 decrease >50% from baseline
    • Suspect HIT if platelet <150k or 50% decrease from baseline platelet count